PART A: PERSONAL INFORMATION:

DOÑA ANA COMMUNTIY COLLEGE DENTAL HYGIENE PROGRAM APPLICATION Demographic Information Please type or write legibly DATE OF APPLICATION: PART A: PERSONAL INFORMATION: 1. NAME Aggie ID# Last First Middle DOB: 2. ADDRESS: Street Apt. # City State Zip Phone Number: (Area code) Phone # E-mail Address: Page 1 Revised 1/4/2019

Dear Applicant, Application from February 1- April 1 by 5pm of current year for August Program Start Date The following attached documents are to assist you in the application process: 1. Application for the Dental Hygiene Program 2. Pre-requisite and General Education Requirements Associate of Applied Science in Dental Hygiene 3. Signature/ Mid-Term Grade form for prerequisite courses in progress at the time of application. 4. Observation form: use for 2 practicing Dental Hygienists in different settings. 5. Orientation participation. Your name must appear on the orientation sign in sheet. The Dental Hygiene Program has limited enrollment and can accept no more than twelve (12) students each Fall. Prerequisite courses must be completed prior to starting the dental hygiene curriculum. Application to the program is not a guarantee of acceptance. Acceptance is competitive and based on individual academic performance in previous coursework and other criteria. Applications will be accepted only between Feb. 1 and April 1 for the class starting in the Fall, semester. Mailed applications must be post marked by April 1 of the current application cycle. Incomplete or late applications will not be accepted. New applications must be submitted each year. There are NO exceptions to this rule. If April 1 st falls on a weekend, the application is due the Monday following April 1 by 5pm. Application packets must be placed in a plain manila envelope addressed to the Dental Hygiene Program and must be complete. Incomplete applications will not be considered. You may return your completed packet to Room 80-Espina Campus or mail your application to: Elmer E. Gonzalez. RDH,MBA, PhD. Dental Hygiene Program Director Doña Ana Community College 3400 S. Espina St [MSC 3DA, P.O. 30001] Las Cruces, NM, 88003-8001. The Dental Hygiene Program has been granted the accreditation status of accreditation without reporting requirements from the Commission on Dental Accreditation of the American Dental Association. All necessary steps are being taken to ensure that this program is of the highest quality and meets or exceeds all accreditation standards. Thank you for your interest in our Program. It can lead you to an exciting and rewarding career! We look forward to your application. Sincerely, Elmer E. Gonzalez, RDH,MBA, PhD. Dental Hygiene Program Director Page 2 Revised 1/4/2019

Doña Ana Community College Dental Hygiene Program Admission Process for the Dental Hygiene Program Application Deadline for Fall is April 1 by 5pm. The Dental Hygiene Program is a limited enrollment program. The student is responsible for all deadlines required by the Dental Hygiene Program for admission. Notification of any changes in name, mailing address, e-mail address or telephone number is the responsibility of the student. An applicant who has been convicted of a felony should contact the State of New Mexico Board of Dental Health or other appropriate State Board of Dentistry regarding eligibility for licensure. In addition, those applicants who are not authorized to live and work legally in the U.S. should contact the Board of Dental Health Care regarding eligibility for licensure. DENTAL HYGIENE PROGRAM APPLICATION PROCESS 1. Admission to DACC. Students who plan to transfer to DACC when accepted to the Dental Hygiene Program may apply. However, even if accepted to the Dental Hygiene Program, they must be admitted to DACC prior to the start of dental hygiene coursework. Note: Admission to NMSU or DACC does not guarantee admission to the Dental Hygiene Program. 2. Submit a current and complete application for the Dental Hygiene Program by April 1 at 5pm. Incomplete applications and late applications will not be considered. 3. As outlined in the DACC Catalog 2015-2017, page 49, completion of all required prerequisites prior to applying to the Dental Hygiene Program. At the time of application, if prerequisite courses are in progress, they will only be considered if a signed Midterm Grade Signature Sheet is filed with the application (see page 11.) 4. All science (chemistry, biology, microbiology) prerequisite credits (see page 7) should be completed within the last five (5) years. 5. Official Transcripts are required. Get your transcript requests in early with each school you are requesting from. This process can take time and if not received by April 1, your packet will be marked incomplete. If you are having transcripts mailed to DACC make sure they are sent to the office of the Program Director. The address is on the first page of this application. NO late submissions of transcripts will be accepted. Official transcripts in unopened sealed envelopes must be enclosed with the application. E- mailed transcripts are acceptable as long as they come directly from the school to the program director s e-mail address. Prerequisite courses must be validated by the admissions officer and/or the dental hygiene Program Director to determine if the transferring course meets the program and accreditation requirements. A final official transcript will be needed to confirm successful completion of any courses that were in progress during the application process. Page 3 Revised 1/4/2019

6. Take the Test of Essential Academic Skill V for Allied Health (TEAS). Tests are given through the Testing Service Office at DACC or arrangements can be made at any local college. Test study guides are available through the DACC bookstore. The guide can be checked out from the DACC library for a limited time period. The TEAS exam process is as follows: a. Schedule the test through the DACC Testing Services, at phone: (575) 527-7569. The schedule of test dates is published month to month in the testing office. Also, testing dates and information are available on the DACC website. b. Contact the Department Secretary in the Dental Programs, room 80. Phone # (575) 528-7071. Request a form to take the TEAS for the Dental Hygiene Program. c. Fill out the form and take it to the DACC Cashier room 102 at East Mesa Campus. Pay the fee for the exam d. Take the paid receipt to the Testing Services Office Room 105 Student Resources Bldg. at East Mesa Campus when you go to take the test. You must also present a picture ID. e. This is a computer generated exam. Notes, calculators or other devices are not allowed. f. At completion of the test, you will be given your test scores. You must include a copy of this exam score sheet in the application envelope. 8. If you are a Registered or Certified Dental Assistant or have certificates from the State of New Mexico to practice specific clinical functions, enclose copies of these certificates in the admissions packet. Current copies of certificates must be included in this packet to be eligible. Current standing of the certificate will be verified by the New Mexico Board of Dental Healthcare. Submission of falsified certificates will be reported to the New Mexico Board of Dental Healthcare and the New Mexico District Attorney s Office. 9. Complete a minimum of 16 hours of observation of TWO (2) Dental Hygiene practitioners in at least two separate employment settings or two separate hygienists. Observation forms must be filled out, signed by the observed dental hygienist and included in the application (see page 10.) Hours can be in either private or public facilities, but must involve observation of actively involved dental hygienists in their employment setting. It is strongly recommended that you wear professional dress/scrubs for the dental office observation. 11. Document attendance at one of DACC s dental hygiene information sessions and include it in the application packet. Information regarding the advisement sessions can be found on our webpage https://dacc.nmsu.edu/dhyg/. If you live more than 150 miles from the college, you are not required to attend. You should call the program to schedule a phone orientation with a full time faculty member. Please contact the Business Operations Specialist at (575) 528-7019 to schedule a phone orientation. 12. If you have attended dental hygiene classes within the last five (5) years, a letter of good standing is required from the Program Director of the institution attended. You must complete ALL prerequisite courses or make sure your prerequisite Page 4 Revised 1/4/2019

coursework is transferable to DACC. You must apply for admission to DACC and the DACC Dental Hygiene Program. DACC Dental Hygiene Program does not guarantee you will be admitted to the program even if you were enrolled in another dental hygiene program elsewhere. Transfer courses are only applicable to prerequisite requirements. All other course work required to graduate from the DACC Dental Hygiene Program must be taken at the DACC Dental Hygiene Program and no dental hygiene courses will be waived. Page 5 Revised 1/4/2019

DOÑA ANA COMMUNTIY COLLEGE DENTAL HYGIENE PROGRAM APPLICATION Please type or write legibly DATE OF APPLICATION: PERSONAL INFORMATION: 1. NAME SSN (or) DACC ID# Last First Middle DOB: 2. ADDRESS: Street Apt. # City State Zip Phone Number: (Area code) Phone # E-mail Address: 3. EMERGENCY CONTACT INFORMATION: NAME: Last First Middle (Relationship to student) ADDRESS: Street Apt. # : City State Zip (Area Code) Phone Number 4. RESIDENCY: State of Legal Residence: County of Legal Residence: 5. CITIZENSHIP: U.S. Citizen Foreign (Which Country?) Provide Documentation of Eligibility for Education in U.S. Permanent Resident Visa Number: 6. List other name(s) used in previous enrollment(s) at this or other institution(s) of higher education: 1. 2. 3. Page 6 Revised 1/4/2019

DACC Course Name & Number Applicant Name: PREREQUISITE AND GENERAL EDUCATION REQUIREMENTS Fill in table for courses you have completed or are taking. All must be completed with a C grade or higher to qualify. PRE-REQUISITES (**TAKEN WITHIN 5 YRS, MUST HAVE COMPLETED BEFORE ADMISSION) ** BIOL 225 - Human Anatomy and Physiology ** BIOL 226 - Human Anatomy and Physiology II ** CHEM 110G Principles and Applications of Chemistry ** CHEM 210 Chemistry for the Allied Health Sciences ** BIOL 221 + BIOL 211L - Intro. Microbiology + Lab ENGL 111G Rhetoric and Composition **HNDS 251 Human Nutrition MATH 120 Intermediate Algebra or higher OTHER PREREQUISITES PSY 201G Intro. to Psychology SOC 101G Introductory Sociology COMM 253G (or) 265G Public Speaking or Principles of Human Communication Status of Course C= Completed IP = In Progress NT = Not Taken Final Grade (If applicable) Date Completed or Anticipated to be Completed College/Univ. where course taken NOTE: Courses being transferred from other institutions must meet the criteria for equivalency for DACC/NMSU courses. DACC Academic Advisors or the DACC Dental Hygiene Program Director can assist students in determining equivalency. Course Equivalent (If not exact course on list) Page 7 Revised 1/4/2019

Applicant Name: I completed a Dental Hygiene Information Session on: (mm/dd/yy) LIST ALL COLLEGES OR UNIVERSITIES YOU HAVE ATTENDED OR ARE NOW ATTENDING. If more than THREE, attach a sheet with the information needed. Academic regulations require that students who have registered at other colleges or universities may not disregard their records at such institutions when making application for admission to credit programs in this college. Students concealing attendance at another college or university and not submitting a transcript from that college or university will be subject to suspension. **Note: List all vocational programs and certifications, which relate to health care including military. Use additional pages if needed. COMPLETE for ALL EDUCATIONAL INSTITUTION(S) Name & Location of Institution: Dates Attended Credit Hours S= Semester Q= Quarters Degree Certificate Awarded In addition to pre-requisite courses, have you taken any other advanced college level math or science courses? If Yes please complete the table. If necessary use additional sheet. Course Name Credit Hours Institution Dates of Course Final Grade Page 8 Revised 1/4/2019

Acknowledgement(Notarized) I certify that all information on my Doña Ana Community College Dental Hygiene Program Application is true, accurate and complete. I understand that withholding or falsifying the requested information; documentation of academic dishonesty; or failure to provide the required documentation will make me ineligible for admission to the Dental Hygiene Program. I understand that filing this form does not guarantee acceptance into the Dental Hygiene Program. Further, if accepted, I must apply for admission to DACC if I am not already enrolled. Acceptance in and graduation from the Dental Hygiene Program does not guarantee licensure or successful completion of board exams. Any remediation courses needed to complete clinical or written board exams will be at the expense of the student. An applicant who is not a U.S. citizen or who has been convicted of a felony should contact the appropriate State Board of Dentistry regarding eligibility for licensure prior to submitting the application. Read the Dental Board Rules and Regulations of each state you plan to practice in to ensure eligibility for licensure. This is the responsibility of the applicant. I understand that once accepted into the DACC Dental Hygiene Program, a background check will be conducted at the student s expense. I hereby declare that all of the information provided is true and complete to the best of my knowledge. Applicant s Name Applicant s Signature: Date: Page 9 Revised 1/4/2019

This form may be reproduced as necessary. DACC DENTAL HYGIENE OBSERVATION DOCUMENTATION Applicant Name: Social Security or DACC ID # Instruction to the Dental Hygienist: Sign the form and attach business card after the applicant fills out the form. Dental Facility # 1 Name of dental hygienist being observed: Number of hours observed: What did you observe? (To be completed by the applicant) Attach Dental Office Business Card Here Signature of Dental Hygienist Date: Printed Name: Instruction to the Dental Hygienist: Sign the form and attach business card after the applicant fills out the form : Dental Facility # 2 Name of dental hygienist being observed: Number of hours observed: What did you observe? (To be completed by the applicant) Signature of Dental Hygienist Printed Name: Date: Attach Dental Office Business Card Here Page 10 Revised 1/4/2019

Mid-Term Grade Signature Sheet Doña Ana Community College Dental Hygiene Program Application APPLICANT S NAME: DATE: COURSE TITLE & NUMBER: INSTITUTION: NAME OF FACULTY PERSON FOR THE COURSE: MID-TERM GRADE: I certify that the grade entered above is a true reflection of the student s achievement in the class at approximately the mid-term of the semester/quarter. I understand that this information is part of the formal Doña Ana Community College Dental Hygiene Program selection process for entry into the program. It will be used to help select the most qualified candidate. I also understand that the student must complete the course with at least a C grade or better for the course to be eligible for consideration in meeting the requirements for entry into the Dental Hygiene Program. Additional Comments: Signature: Date: Printed Name and Professional Rank: Phone Number: E-mail Address: This form may be reproduced as necessary. Page 11 Revised 1/4/2019

RECEIPT FOR TEAS EXAM DENTAL HYGIENE PROGRAM Directions: 1. Fill out the information below (please print). 2. Pay for TEAS at the DACC Cashier s Office, Room 118 3. Have receipt stamped by Cashier. 4. Schedule to take the test, 527-7569. 5. Take receipt with you and give to the testing center when you take the exam. DATE BANNER NUMBER LAST NAME FIRST NAME M.I. AMOUNT RECEIVED HEALTH SCIENCES DIVISION DENTAL HYGIENE PROGRAM TESTING/DENTAL HYGIENE PROGRAM INDEX NUMBER: 400737-506100 Authorized Signature/Stamp Indicating Payment Received Page 12 Revised 1/4/2019

Is Your Doña Ana Dental Hygiene Application Complete? The Application Packet should be sent as a packet. All documents must be included in the mailing envelope. Individual documents will not be accepted. No exceptions. Be sure to: Print your name on the top right of each page. Complete all spaces on the application forms. If your address changes after submission of this packet please notify the Program Director immediately. DACC will not be responsible for notification of applicant status due to returned mail. Submit official transcripts from all institutions attended- if sending transcripts, they must be mailed to the Program Director at the address below. Include a copy of all current dental assisting certifications earned (CDA/RDA; Coronal Polish, Nitrous Oxide Monitoring, Sealant Placement, Radiography, etc.) Include the TEAS score sheet. Include the Dental Hygiene Observation form that documents that you have a minimum of 16 hours of observation of two different hygienists in at least two different employment situations. Complete the date on the application form that you attended a DACC dental hygiene information session. Enclose a letter of good standing from the director of the program of the institution of any Dental Hygiene Program you have attended in the last five (5) years. Have the application notarized. Sign and date the application. Return to Room 80 DACC Central Campus or if mailed postmark must be on or prior to April 1. NO late packets will be accepted. NO exceptions. Please do not include additional documents that are not required. We do not need letters of recommendation, etc. These additional documents make it more difficult to discern if you have submitted the required documentation. Letters of recommendation are NOT considered for acceptance. Note: Submitting false information is grounds for dismissal or non-acceptance from/to the Dental Hygiene Program. A new application for the Dental Hygiene Program must be submitted each year. Attendance at a pre-advising session will be required before reapplying. Submit completed applications to: Elmer E. Gonzalez, RDH,MBA, PhD. Dental Hygiene Program Director Doña Ana Community College 3400 S. Espina Street MSC 3 DA P.O. 30001 Las Cruces NM, 88003-8001 Page 13 Revised 1/4/2019